CAPS Services Request Form

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Thank you for your interest in our services. Please complete the form below for the areas that are applicable to your needs. Our website also has additional information about our full range of services- CAPS Website.

If you are concerned about someone....

You will want to contact with Student Mental Health Coordination Services 805-893-3030 (please leave a message) or you can fill out their form located on their website- SMHC Distressed Student Protocol

Long-Term Therapy or Community Referral

You do not need to schedule a Brief Assessment to request a referral. You only need a referral if you have UC SHIP insurance. For additional info: Long-term/ Community Referral

To request a referral send an email to sa-capsreferrals@ucsb.edu (Note that this is a mailbox that focuses solely on referrals and is monitored weekly)

Let's Talk

The Let's Talk program provides a type of informal mental health consultation over the phone. All Let's Talk appointments are scheduled via Shoreline. Availability is limited so if no appointments are listed we may not have any current openings. Let's Talk

Please note that these form submissions are NOT monitored 24/7. If you need immediate mental health support, please call (805) 893-4411 and press 2 to speak with a live clinician. If this is a situation that involves potential harm to self or others, please call 911 immediately.

Submissions will be reviewed during CAPS business hours - http://caps.sa.ucsb.edu/about-us/contact-us-hours-location.

PERM# (if you are a UCSB student)

Phone Number *

May we leave a voicemail if you are unable to pick up the phone? *

Yes

Email Address *

What is your preferred form of communication for our follow up? *

Phone Call/Voicemail (follow up email may be sent if unable to make contact via phone)

How can we help you? *

Initial Brief Assessment (you are a student and you would like to initiate services at CAPS)

Returning Client Appointment Request (you are a past or current client and you want to schedule another appointment)

Group Counseling Pre-Screen (you have reviewed https://caps.sa.ucsb.edu/services/group-counseling/ & have submitted an interest form)

ADHD Pre-Screening (you are a student interested in the ADHD Screening process and you have reviewed the website information - https://caps.sa.ucsb.edu/services/caps-adhd-evaluation) - [these appointment requests will be responded to via phone call given the limited number of appointments]

General Question (there is a box below for your to enter your question)

If you selected Brief Assessment please let us know your availability. Brief Assessment appointments are available Monday through Friday between 10 am- 12 pm and 1 pm - 3 pm. Plan for paperwork time + about a 15 minute appointment. Please include any additional scheduling information we should be aware of.

If you selected Returning Client Appointment Request, would you like to see the same therapist you have seen most recently? Therapist availability will be based on a variety of factors but your response will help our administrative and clinical teams review these appointment requests. (If you are not a returning client, please skip this question or mark N/A.)

Yes

Unsure

Not Applicable (N/A)

Clear selection

If you selected Group Counseling Pre-Screen, which group(s) have you submitted an interest form for? (if not interested in Groups, please skip this question)

If you selected General Question, please submit your question here.

By checking this box, you acknowledge that you understand that this request form is NOT monitored 24/7 and that you will seek out emergency services if you are in a situation that could involve harm to self or others. *

I understand

Required

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